Curriculum standards
Knowledge guides
LG16: Arthritis
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.
Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.
Presentations
- Acutely unwell
- Decreased joint range of motion
- Fever
- Functional impairment
- Joint pain
- Joint swelling
- Limp
- Rash
- Stiffness, such as morning stiffness or with inactivity
Conditions
- Arthritis in the context of infection:
- mycobacterium-related
- post-infectious, including transient synovitis
- post-streptococcal, including acute rheumatic fever
- septic arthritis, acute – with or without osteomyelitis
- Juvenile idiopathic arthritis (JIA):
- enthesitis-related arthritis
- oligoarthritis, including extended or persistent disease
- polyarthritis:
- rheumatoid factor negative
- rheumatoid factor positive
- psoriatic
- systemic–onset
- unclassified
- JIA-associated medical emergencies:
- macrophage activation syndrome (MAS) / secondary hemophagocytic lymphohistiocytosis (HLH)
- systemic onset JIA pericarditis / cardiac tamponade
- JIA-associated uveitis
- Non-JIA causes of inflammatory arthritis:
- associated with other rheumatic conditions
- chromosomal syndrome-associated, such as:
- DiGeorge / 22Q syndrome
- Down syndrome
- Turner syndrome
- coeliac disease-associated
- immune deficiency mediated
- inflammatory bowel disease-associated
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Adult-onset inflammatory arthritis:
- adult-onset Still disease
- axial spondyloarthritis:
- non-radiographic
- radiographic
- crystal-induced, such as gout
- osteoarthritis
- psoriatic arthritis
- reactive arthritis
- rheumatoid arthritis:
- seronegative
- seropositive
- Conditions that mimic JIA
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Epidemiology
- Age of onset for different JIA subtypes
- Annual incidence and prevalence
- Genetic factors associated with JIA
- Geographic variability in JIA subtypes
- Male to female ratio for different JIA subtypes
Pathophysiology
- Principles of autoinflammation and autoimmunity
Treatments
- Considerations for medications used in the treatment of JIA:
- drug interactions
- duration and discontinuation
- mode of action
- route of administration
- safety monitoring
- side effect profiles
- Corticosteroids:
- intra-articular
- intravenous
- oral
- Disease-modifying antirheumatic drugs (DMARDs):
- biologic DMARDs (bDMARDs), such as inhibitors of:
- B-cells
- co-stimulatory inhibition
- interleukin-1
- interleukin-6
- interleukin-12/23
- interleukin-17
- tumour-necrosis factor α
- conventional DMARDs (cDMARDs), such as:
- hydroxychloroquine
- leflunomide
- methotrexate
- sulfasalazine
- small molecule targeted synthetic DMARDs (tsDMARDs):
- Janus kinase (JAK) inhibitors
- biologic DMARDs (bDMARDs), such as inhibitors of:
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Treatments for macrophage activation syndrome
Clinical assessment tools
- JIA:
- damage scores
- disease activity scores
- outcome measures
Investigations
- Baseline investigations looking for inflammation
- Infection screening as relevant, such as antistreptolysin O titre
- Monitoring blood tests for patients on treatment
- Pre-immunosuppression screening, such as latent tuberculosis screening
- Role of different imaging modalities:
- in diagnosis of arthritis, and consideration of differentials
- in surveillance of disease activity and assessing damage over time
- Specific immune testing in inflammatory arthritis, such as:
- anticyclic citrinullated peptide
- antinuclear antibody
- human leukocyte antigen (HLA) B27
- rheumatoid factor
- Testing for macrophage activation syndrome
- Work up for differentials of chronic inflammatory uveitis
Physical examination
- Comprehensive physical examination for a child with suspected inflammatory arthritis of the musculoskeletal system and other relevant systems, such as:
- abdominal
- cardiac
- ear, nose, and throat
- respiratory
- skin
- Screening examinations:
- paediatric gait, arms, legs, and spine (pGALS)
- paediatric regional examination of the musculoskeletal system (pREMS)
Procedures
- Intra-articular steroid injections
Specific considerations
- Function-related outcomes
- JIA:
- cardiovascular outcomes
- extra-articular manifestitations
- mortality rates in systemic-onset
- multidisciplinary teams and their importance in the management of JIA, including:
- occupational therapy
- physiotherapy
- specialist nurse
- Management of chronic immunosuppression:
- bone health
- vaccinations
- Potential for secondary pain sensitisation in patients with inflammatory arthritis
- Screening for and management of chronic uveitis